Cultural competence: moving beyond sentiment

A growing body of evidence confirms that understanding cultural differences not only is the right thing to do, it’s the smart and necessary thing to do.

This is especially true in health care, where working within our patients’ cultural framework – their values, beliefs, language, customs or socioeconomic status – can mean the difference between life and death. The Joint Commission now requires hospitals to promote culturally competent care, and this year the Oregon Legislature passed a bill that allows medical boards to require cultural competence training as a licensing requirement.

As we know, health reform will bring up to 240,000 newly insured Oregonians. Many of these patients will be ethnic and racial minorities, and many more will be economically disadvantaged. Some may be disabled, elderly or from rural communities, and some will have non-mainstream beliefs around health and illness.

In addition, federal reimbursement models are placing new emphasis on patient satisfaction, and health care is undergoing a dramatic shift toward managing patients’ overall health. Combine all these factors, and patient-centered, culturally competent care becomes more important than ever.

So what exactly is cultural competence? It helps to understand some definitions:

Cultural sensitivity allows us to understand how culture shapes our patients’ behaviors so that we can adapt accordingly.

Cultural competence is a set of attitudes, practices, policies and structures designed to respect and accommodate our diverse beliefs and values.

At Providence, cultural competence includes providing interpreters for patients and their families who don’t speak English; making special accommodations for people with disabilities; respecting how our patients define “family” when planning aftercare; and seeking to understand how various cultures view death and dying.

Health care organizations are promoting cultural competence not only because of the external forces noted above, but also because this purposeful approach will bring the most benefit to patients. Acknowledging our patients' culture and belief systems eases early access to care, improves treatment compliance and helps prevent illness. Research on diabetes care, for example, found that patients who received interventions consistent with their values, beliefs and preferred way of getting information had significantly better outcomes than those who received standard interventions.

Boosting your diversity quotient
I’ve heard many people say, “I don’t see color; I don’t see difference.” This is untrue and unwise. We all have certain stereotypes etched into our thinking. More importantly, if we ignore cultural differences, we miss opportunities to build stronger relationships. If a patient is from a culture in which healers are not to be questioned, for example, you can take steps to even that power dynamic. If a patient is part of a group that leans heavily on family members to help make medical decisions, you’ll know to invite the family into care conversations from the start.

Asking questions related to a patient’s culture, ethnicity, race, religion, economic status, sexual orientation or disability can be uncomfortable. Will the patient take offense? Will your intent be misunderstood? But because their answers can reveal hidden obstacles to better communication, it’s important to get past that discomfort.

I advise providers to apologize up front. Tell your patients that if you say something wrong it’s not out of malice, and give them permission to correct you. Ask patients to share their beliefs about illness and medical treatments. Learn their values about spirituality, culture, and ethnic or racial identity. Allow them to lead or educate periodically, thus leveling out the relationship.

Few, if any, patients have resisted such questions, allowing us to become a regional leader in collecting valuable data on our diverse patient populations.

If you’re talking only to people who look like you and think like you, your knowledge base will be limited. Try building a “diversity Rolodex” of people to whom you can turn for cultural insights.

To measure how well you know your culturally diverse patients, try the National Center for Cultural Competence’s online test. Health Care Chaplaincy offers a useful primer on specific religions and cultures – and how they influence behaviors in health care.

Finally, weave cultural competence into your practice’s policies, behaviors and performance evaluations. Not only will you improve your own cultural literacy and effectiveness, you’ll improve the lives of your patients and, in some cases, your colleagues.